Well-differentiated papillary villoglandular adenocarcinoma of the uterine cervix with a focal high-grade component: is there a need for reassessment?

Well-differentiated villoglandular adenocarcinoma of the uterine cervix is characterized by an exophytic growth pattern with variably sized papillae that are lined by stratified columnar cells with no more than moderate cytologic atypia. Based on the favorable outcomes in most of the previously reported cases, it has been suggested that some patients with this subtype may be managed conservatively. The case described herein is an otherwise prototypical well-differentiated villoglandular adenocarcinoma but which was associated with a 4.9-mm focus of poorly differentiated carcinoma at its invasive edge. A review of the literature revealed a variety of findings that suggests a need to reassess the potential morphologic and biologic spectrum of this group of tumors. Five of the approximately 89 reported cases were associated with a higher-grade component of the same or a different histologic subtype. At least one patient with apparently stage 1A1 disease was found to have a positive lymph node. Another patient with stage 1B1 disease but no stromal invasion died of her disease following multiple recurrences. Finally, the frequency of lymphovascular invasion and/or lymph node involvement in recent series far exceeds what was found in the two original series. Our case suggests that well-differentiated villoglandular adenocarcinoma is not a diagnosis that should be unequivocally rendered on a small biopsy since other components may be present and the patients may be undertreated. We urge caution when conservative management (cone biopsy alone when margins are negative and there is no lymphovascular invasion) is offered to patients with this tumor since knowledge about its true biologic spectrum appears to still be in evolution.